The role of NSAIDs in pain management
Nonsteroidal anti-inflammatory drugs (NSAIDs)1 are effective analgesics for pain with an inflammatory component. They are used for acute nociceptive pain and cancer pain, and have a limited role in the management of chronic noncancer pain. NSAIDs are ineffective for neuropathic and nociplastic pain.
- NSAID adverse effects are more likely in patients with certain comorbidities (eg renal impairment, cardiovascular disease, active peptic ulcer disease).
- NSAID adverse effects are more likely with higher doses or prolonged use. Individual NSAIDs differ in their potential to cause specific adverse effects.
- There are few reasons to avoid NSAIDs in acute pain because adverse effects are less likely with short-term use (ie less than 5 days) and the benefits of therapy are greater.
- The potential for adverse effects is increased when NSAIDs are used longer term for chronic pain, so additional caution is warranted. Prescribers should consider both the recommendations in this topic and those in Considerations for NSAID use in the Rheumatology guidelines.
For specific precautions and contraindications to NSAID use, see Cardiovascular adverse effects of NSAIDs, Gastrointestinal adverse effects of NSAIDs, Renal adverse effects of NSAIDs, NSAIDs and postoperative recovery, Potential effects of NSAID use on conception and Potential harms of NSAID use during pregnancy.
Avoid nonselective NSAIDs in patients with NSAID-exacerbated respiratory disease.
|
System |
Adverse effects |
Comments |
|---|---|---|
|
increased blood pressure fluid retention myocardial infarction stroke cardiovascular death |
NSAIDs can be used short term (up to 5 days) for acute pain in patients with CVD or at high risk of CVD—except postoperatively in patients who have had cardiac surgery NSAIDs should not be used for chronic pain in patients with CVD or at high risk of CVD celecoxib, ibuprofen or naproxen may be preferred | |
|
upper abdominal pain gastric erosions gastrointestinal ulceration (eg oesophageal, gastric, duodenal) gastrointestinal bleeding gastrointestinal perforation |
NSAIDs should not be used in people with active peptic ulcer disease or gastrointestinal bleeding limit NSAID use for acute pain to 5 days to reduce the risk of gastrointestinal toxicity compared to nonselective NSAIDs, COX-2–selective NSAIDs (eg celecoxib, etoricoxib) are less likely to cause gastrointestinal toxicity, provided aspirin is not used concurrently | |
|
acute or chronic renal impairment |
NSAIDs should not be used in people with an eGFR less than 30 mL/minute additionally, in acute pain, NSAIDs should not be used in people at risk of haemodynamic instability who have an eGFR less than 80 mL/minute, or who have postoperative or posttraumatic haemodynamic instability celecoxib may be preferred | |
Note:
COX-2 = cyclo-oxygenase-2; CVD = cardiovascular disease; eGFR = estimated glomerular filtration rate; NSAID = nonsteroidal anti-inflammatory drug NB1: Older people are at greater risk of NSAID-related adverse effects; assess their need for NSAID therapy carefully. | ||
Limit the use of intravenous parecoxib to patients who are unable to take oral medications or who have biliary or renal colic. It is the consensus of the Pain and Analgesia Expert Group that repeat doses of intravenous ketorolac should be avoided because of ketorolac’s unfavourable adverse effect profile—gastrointestinal ulceration can occur within 5 days of ketorolac use.